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0656 (SFD)PERMIT APPLICATION �3 City of La Duinta Department of Building and Safety This permit becomes void if work not commenced within 180 days Irom date of issuance, OR, if work has been suspended or abandoned for a period of 180 days, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and ellect- License Class Lic- Number OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption- Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars (S500-): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec, 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale, If, however, the bu ilding or improvemnl is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale,). ❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law,). ❑ 1 am exempt under Sec.- . B. & P,C, (Attached Certificate) Owner WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.). - Policy No. Company ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the City Building Inspection Department or City Date Applicant Department, APPLICAN _NAME IV F�MI) ADDn$S !7 CITY/COMMUNITY,/STATE/ZIP JOB SYTE/ ADDRESS/SPACE CITY/COMMUNITY/STATE/ZIP BOK PAG PRC c TWN RNG SE S TRACT L T A MOD SIB TRACT NAME OWNER NAME (L, F. MI) CONTRACTOR -FIRM NAME ADDRESS CITY/COMMUNITY/STATE/ZIP PHONE N LICNC N ARC/ENG FIRM NAME ADDRESS CITY/COMMUNITY/STATE/ZIP PHONE N LICNC N USE OF PERMIT BL I I ZON FSB SSB SSB RSB OFC ZONE ORD N LOT SZ END SIDE CERTIFICATE OF. EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE: This section need not be completed if the permit is for one hundred (S100) o, less. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'CompensationLaws of California. Date- Applicant NOTICE TO APPLICANT: If, after making this Certificale of Exemption, you should become subject to the Workers; Compensation provisions of the Labor Cade, you must forthwith comply with such provisions or this permit shall be deemed revoked, DIVISIONOF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required todescend,will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirly-six (36) feel high, (Chap 12, Grp 2, Art 2.Sec341,TitleB.. C. A. Q ❑ As owner -builder,' I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work Irom that division, 0,;Division of Industrial Safety Permit Na Applicant CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and slate that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the above -mentioned property for inspection purposes. Signature of Applicant or Agent Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the information given is correct. I agree to comply with all slate laws and county ordinances relating to buidling construction, and authorize a representative of the City of La Duinta Department of Building and Safety to enter upon the property for which I have applied for this permit for the purpose of making inspections. Signature of Applicant or Agent Print Applicant/Agent Name Date APPL/PRMT 0 6 DATE_ _{ + 7 L.�f 5 6 - r •F f /- TOTAL . FEE VALUATION BLDG. DEPT. NO. OPERATION DATE INSPECTOR NO. OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS 1 Set Backer 33 Ventilation System 2 Ftgs & Frms / 34 Plenums & Ducts 2A Slab Grade 35 Furnace Compart. 3 Steel 36 Inlets & Outlets 4 Grout Blocks 37 Combustion Air 5 Bond Beams FOlJiCi 38 Compressor 6 Roof Deck 39 Appl. Clearance 7 Framing 40 Fire Damper 8 Vents 41 Smoke Detection Device 9 Garage Fire Wall 42 Commercial Hood 10 Fireplace P.L. ❑ 43 1Final 10A fireplace T.O. ❑ NPON ADDITIONAL INFORMATION ' 5 SEWAGE SYSTEM SIZE &LOCATION 11 Exterior Lath 12 Internal LathCl. 12A Drywall 13 Finish Grade INSULATION Thick ••R•• Value 7A Walls (Batts) 126 Ceiling (Batts) 12C Ceiling (Blown) 14 Final PLUMBING APPROVALS 15 Ground Plumb 16 Water Piping 17 Rough Plumb 18 Vents 19 Sewage Disposal �L 20 Sewer 21 Water Heater 22 Water Softener 23 Water Service r 24 Gas Test `ra 25 Final Tank Pit L. Line ELECTRIC APPROVALS REAR OF PROPERTY LINE pI Ph STREET NAME. 26 Power Pole 27 Conduit 28 Service Entrance 29 Wiring 29A Grounding Wire 29B Bonding 30 Fixtures 31 Service 32 Final DEPARTMENT OF BUILDING & SAFETY COUNTY OF RIVERSIDE CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES f`� q S yft® UNITS 1ST FL. " SO. FT. ® - COMMUNITY OWNER L/ YARD SPKLR SYSTEM j 2ND FL. SQ. FT. ® USE OF PE MIT ♦CGkrip ® F.C.C. MOBILEHOME SVC. BAR SINK POR. SQ. FT. ® SI FT. 6 O 94 POWER OUTLET ROOF DRAINS $ GAR. SO. ® PLA NO. PLAN CH KER DATE UPP. TO PERWT CAR P. SQ. FT. ® DRAINAGE PIPING WALL SQ. FT. ® dr� ZA L DRINKING FOUNTAIN SQ. FT. ® Dbl $ URINAL ESTIMATED CONSTRUCTION VALUATION $ DATE APPROVED WATER PIPING NOTE: Not to be used as property tax valuation cod FLOOR DRAIN MECHANICAL FEES $ WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASH ER(AUTO)(DISH) APPLIANCE DRYER PLAN CHECK GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY CONSTRUCTION FEE AIR HANDLING UNIT CFM $ 3 ftcc KITCHEN SINK ABSORPTION SYSTEM B.T.U. ❑ ❑ GRADING ROAD DEPT TEMP USE PERMIT SVC WATER CLOSET Q COMPRESSOR HP ELECTRICAL FEE Dbl POLE,TEM/PERM LAVATORY cs HEATING SYSTEM FORCED GRAVITY i AMPERES SERV ENT SHOWER SMI FEE BOILER B.T.U. $ SO. FT ® e. BATHTUB SQ. FT. ® ¢ WATER HEATER 7 MAX. HEATER OUTPUT, B.T.U. O.FT.RESID ®1+A¢ 17SEWAGE DISPOSAL hdw Dbl $ SQ.FT.GAR@V,,, �j HOUSESEWER `p GASPIPING PERMITFEE TOTAL FEES $ UPL.CK. PERMIT FEE PERMIT FEEDBL AUDIT TOTA FEES MIC FEE MECH.FEE E CONST. FEE ELECT.FEE SMI FEE PLUMB.FEE �. D S TREES REQUIRED e ♦ JOB ADDRESS COMMUNITY OWNER t USE OF PE MIT VALUATION F.C.C. GROU TYPE SI MICRO FILM FEE Cop $ PLA NO. PLAN CH KER DATE UPP. TO PERWT dr� ZA L MECH. FEE Dbl $ E N TAPPROVED DATE APPROVED 1-5 cod PL. CK. FEE $ CLEARANCEREQ'D PLAN CHECK CONSTRUCTION FEE Dbl $ 3 ftcc PLUMBING ❑ ❑ GRADING ROAD DEPT ELECTRICAL FEE Dbl $ cs ELECTRICAL i ❑ ❑ HEALTH DEPT PLANNING DEPT SMI FEE $ 6 ❑ LAND USE PLUMBING FEE Dbl $ STRUCTURAL FIRE MARSHAL `p TOTAL FEES $ AUDIT M.O. ❑ N.C.❑ CASH ❑ CHECK ❑ C.R.T. RECEIVED BY TREES REQUIRED REMARKS: 70t SEWAGE SYSTEM s T LL P ego SEWER DISTRICT / FORM 284.58 (REV. 8/79)